Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis

Medical errors on part of the healthcare providers due to lack of attention result in adverse events or near-miss events. These events are preventable errors that can be minimized by providing healthcare providers with additional help through the introduction of technological aid. 

Implications of an Adverse Event 

An adverse occurred in the healthcare setup where I work which resulted in fatalities. The adverse event was due to a medication error on part of the prescriber who had mistakenly administered a drug that led to an instant decrease in blood pressure and the patient underwent severe hypotensive crises which induced a coma in the patient. 

This adverse event hurt the stakeholders (patients and the hospital). Following this incident, many the number of patients who came to receive healthcare services decreased drastically. The hospital began to lose its financial, social, and economic standing as more of its patients started to get healthcare services from other hospitals. 

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Short-term and Long-term effects for Stakeholders

The short effect is that the patient will be unsatisfied, they will be cautious of the care that they will receive at the hospital and the healthcare providers will be demoralized by their inability to prevent the medication error that endangered the patient’s life. The long-term effect will be the lack of patients willing to require healthcare services from the hospital. In the healthcare system, the investors and owners will go bankrupt and will lose their business as the patient would not require healthcare services from it. 

Assumptions

The analysis is based on the assumption that the healthcare providers due to being overburdened make medical errors that lead to fatalities, mortality, and morbidity rate. As a result, patient dissatisfaction increases and patients refuse to receive treatment from the same hospital. 

The sequence of Events/ Missed Steps 

The sequence of events that led to the adverse event involved the lack of ability of the healthcare providers to evaluate and assess the effect of the drugs which were to be administered to the patients. The cardiologist came, assessed the patient’s emergency condition, and prescribed the drugs that needed to be administered. The cardiologist was in a hurry and needed to attend to other patients, due to which he prescribed the wrong medication (missed step 1). The nurses were instructed to follow the prescription and since they did not have enough knowledge to question the drug prescribed, they blindly administered the patient with medication (missed step 2). 

The medicine which was administered was Sodium Nitroprusside which instantly decreased the patient’s blood pressure and induced a coma. The patient already had low blood pressure and needed treatment for it, instead of prescribing Atropine, the cardiologist prescribed Sodium Nitroprusside which is administered in case of severe high blood pressure. The patient was shifted to ICU (Intensive Care Unit) to nullify the effect of the drug. 

The above-mentioned missed steps were responsible for the adverse event which occurred. The factor which contributed to the adverse event was the overburden of the healthcare providers which resulted in a lack of time management of the healthcare providers. The lack of management resulted in the wrong prescription of the drugs which led to adverse events and endangered the patient’s life.